Massive osteoradionecrosis of facial bones and soft tissues

Osteoradionecrosis (ORN) is one of the most serious and uncommon complications in head and neck irradiation for cancer. It is defined as a combination of necrotic soft tissue and bone not being able to heal spontaneously, it demonstrates a general resistance to antibiotics and requires conservative surgical management. Even with modern radiation therapy, its incidence is highly unpredictable and varies between 4-30%. We report on a patient with a huge open cavitation in the cheek, communicating with the mouth and extending to contralateral periodontal gingival and temporal fossa. He had been treated with radiation therapy for nasopharyngeal cancer 5 years ago and presented with restriction of the opening of the mouth. Osteonecrosis complicated with osteomyelitis was evident in bilateral mandible and maxillary bones and the temporal bone. The ramus of the mandible and zygomatic arc were resected, subtotal maxillectomy was performed and the defect was repaired by a free double island flap from the scapular and parascapular osteocutaneous latissimus dorsi muscle flap supplied by subscapular artery. To our knowledge, this is the most extensive bone and soft tissue destruction due to radiation reported in the literature.